Percutaneous endoscopic gastrostomy (PEG) feeding has become a well-established method
of enteral feeding. Many patients undergo long-term feeding and require tube changes
during this period. The preferred method of button-PEG tube replacement is via the
endoscopic route, which requires the endoscope to be passed twice. Patients are sedated
relatively heavily and re-intubation can be difficult. We describe a simple and reliable
method of combined bumper and PEG tube removal.
Following intubation, the old PEG tube is grabbed with a snare. Once secure, the tube
is cut a few centimetres from the skin surface and a silk thread is inserted through
it (Figure [1]). The thread is secured from the outside with a plastic introducer, used as a bung,
that is pushed alongside it into the tube (Figure [2]). This introducer comes as part of standard Fresenius PEG sets (Fresenius Kabi,
Bad Homburg, Germany), but can be custom-made from appropriately sized plastic tubing.
The old PEG tube is removed through the oesophagus, together with the thread, which
is then used to insert the new PEG tube in the usual way. The potential problem of
losing the plastic introducer during retrieval has not arisen in our experience, but
if this did happen the introducer is small enough to pass through the gastrointestinal
tract without causing problems.
Figure 1 The silk thread is seen entering the stomach through the old PEG tube. A snare is
positioned around the PEG tube and closed tightly.
Figure 2 The silk thread is secured with a plastic bung which is pushed tightly alongside the
thread into the lumen of the old PEG tube. The old PEG tube and the thread are then
pulled out through the oesophagus and the thread is used to pull the new PEG tube
into place.
A number of alternative techniques for replacing PEG tubes have been described, including:
”crosswise“ snaring of the bumper and guide wire, pushed through the old PEG tube
[1]; tight snaring of the old tube and passing of a soft-tipped guide wire through it
[2]; complex internal knotting of the guide wire with a snare [3]; and suturing of a guide wire to the external lumen of the old PEG tube [4]. These methods are either unreliable, complex, possible only when using particular
PEG tubes, or they require additional equipment. We believe that the method described
by us is the simplest and most reliable method of endoscopic PEG replacement and would
recommend it as a standard approach for this procedure.
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